Treatment of Onychomycosis* with the JOULE® ClearSense™
G. Todd Bessinger, MD, PhD
INTRODUCTION
Onychomycosis is a non-life threatening infection of the nails caused predominantly by the
dermatophytes Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum,
and to a lesser extent by yeasts (e.g., Candida species) and non-dermatophytic molds. Although
visual changes are often observed in the nail, a proper diagnosis using a test designed to detect the
presence of nail fungus is often performed to rule out other causes for the nail’s changed appearance.
The worldwide prevalence of onychomycosis is up to 5%, and the risk of infection increases
with age. Treatment options include topical antifungal medications, nail removal, oral antifungal
medications, and lasers. The choice of therapy depends on the disease severity, previous treatments,
other medications the patient is taking, physician or patient preference, and cost. With rising patient
awareness, the global market for treatment of onychomycosis is increasing and in 2010 was estimated
to be $3.6 billion (Podiatry Today).
Topical and Oral Treatments
Home remedies (e.g., bleach and permanganate soaks, Castellani carbofuchsin), although safe,
inexpensive, and widely used, have limited effectiveness. Topical antifungal medications such as
terbinafine (Lamisil Cream) are generally recommended if less than half of the nail is affected or if
the patient cannot take oral agents. Topical treatments are unable to penetrate the nail plate and
recurrence may occur quickly after the regimen is discontinued1. Despite these drawbacks, topical
medications may be recommended for use in combination with oral medicine2. Oral agents such as
the azoles and terbinafine are the current gold standard for the treatment of onychomycosis. Unlike
topical treatments, oral agents can penetrate the nail bed systemically and offer shorter treatment
periods with higher, yet suboptimal, cure rates.
Multiple studies have revealed less than optimal cure rates for the oral azoles, a class of antifungal
compounds that inhibit a fungal enzyme important for producing ergosterol, a vital component of
the fungal plasma membrane. For oral itraconazole, the mycological cure rate in a premarketing
trial was 54%, clinical success was 35%, and complete cure was 14% after a 12-week course of
treatment. (Clinical success denotes visual clearance of all signs of fungal infection while a complete
cure denotes the clearance of fungal infection as demonstrated by negative mycological culture with
clear or minimal nail involvement.) Adverse effects included headache, gastrointestinal problems,
and skin disorders. Itraconazole is also contraindicated in patients with congestive heart failure. In
addition, patients receiving itraconazole continuously for one month or longer are advised to monitor
liver function as a few cases of hepatitis, liver failure, and death have been reported. Some of these
*FDA Cleared for the temporary increase of clear nail for patients with onychomycosis
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Treatment of Onychomycosis with the JOULE ClearSense |
G.Todd Bessinger, MD, PhD
cases had neither pre-existing liver disease nor a serious underlying medical condition. Fluconazole,
another oral, antifungal, azole compound, is associated with nausea, pruritus, headache, and liver
enzyme anomalies3. Furthermore, the azole class of compounds cannot be taken with many other oral
medications such as the statins or calcium channel blockers due to dangerous drug interactions. Given
the less than optimum cure rates and undesirable sequelae, the azoles are largely considered only
moderately effective for treating nail fungus.
Oral terbinafine, a compound that also disrupts ergosterol synthesis, has fared much better than the
azoles. Sigurgeirsson and colleagues4, in their 5-year blinded prospective follow-up study comparing
the effectiveness of terbinafine and itraconazole, reported a 46% mycological cure rate in terbinafinetreated patients and a 13% mycological cure rate in itraconazole-treated patients. Mycological and
clinical relapse rates were significantly lower in patients treated with terbinafine. A post-marketing
study5 of the safety of terbinafine for the treatment of onychomycosis in 25,884 patients showed a
10.5% incidence of adverse events, with gastrointestinal effects comprising 4.9% and skin problems
accounting for 2.3%. These events were generally mild, temporary, and reversible. Terbinafine was a
possible or probable cause of only 0.04% of serious adverse events and drug interactions were not
observed. In this set of studies, oral terbinafine had less adverse events and a higher cure rate than
the azoles; however, a high cure rate remains elusive for oral antifungal agents.
In summary, oral antifungals, though more useful than topical treatments, may be associated with
potential hepatic toxicity and life-threatening drug interactions1. Whether the therapies are combined
or used alone, there continues to be widespread dissatisfaction with these modalities as their
cure rates are quite low6-10. A need exists for a safer and more clinically efficacious treatment for
onychomycosis.
Laser Treatments
Laser energy offers many advantages over traditional therapies for onychomycosis. Treatments are
less frequent and they are given in the physician’s office, avoiding compliance issues with topical and
oral therapies. Potential drug interactions and renal or liver toxicity with the oral treatments are also
avoided. Preliminary evaluations have been reported for a 1064-nm and 532-nm Q-switched laser, and
a combination 870 nm/930 nm laser11. The safety and efficacy of an FDA-cleared Nd:YAG, 1064 nm
laser for the treatment of toenail fungus has been reported with favorable outcomes.
One of the first 1064-nm lasers reported for treating onychomycosis uses a small spot size of 1 mm,
consumables, and requires 45 to 60 minutes for a single treatment. Without adequate measures in
place to detect optimum treatment temperatures, this laser treatment can result in both undertreated
areas and areas of hotspots leading to suboptimal treatment.
Temperature
Indicator
Figure 1: JOULE ClearSense
with audible and visible
temperature sensing capability.
Unlike other laser systems, the JOULE ClearSense (Sciton Inc., Palo Alto, CA) accessory for the 1064
nm laser provides real-time audible and visual temperature feedback during treatment, increasing
safety and optimizing clinical results in the treatment of onychomycosis. The accessory is shown in
Figure 1. With Sciton’s expandable platform technology and 1064 nm wavelength, physicians may also
be able to treat other dermatologic conditions including but not limited to warts, vascular conditions,
wrinkles, and hypertrophic and keloid scars.
CASE STUDIES
Case 1
A 50-year-old woman with distal subungual onychomycosis of the right great toe received two
ClearToe treatments spaced one month apart (Figure 2). Parameters for each treatment were 5 J/cm2
fluence, 0.3 ms pulse width, 3 Hz, and 4.8 W. The patient experienced no discomfort and adverse
events were not observed.
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Treatment of Onychomycosis with the JOULE ClearSense |
Pre-ClearToe treatment
G.Todd Bessinger, MD, PhD
2 months post 2 treatments
Figure 2: The right great toe of a 50-year-old woman. The infected areas (gold color) before ClearToe treatment are along both sides
of the nail. Two months post the second treatment there is significant proximal clearing of the nail plate.
Case 2
A 53-year-old man with onychomycosis of the right great toe received two ClearToe treatments spaced
one month apart (Figure 3). Parameters for each treatment were 5 J/cm2 fluence, 0.3 ms pulse width, 3
Hz, and 4.8 W. The patient experienced no discomfort and adverse events were not observed.
Pre-ClearToe treatment
2 months post 2 treatments
Figure 3: The right great toe of a 53-year-old man. The infected nail plate shows proximal clearing two months after the second
ClearToe treatment.
DISCUSSION
During the treatment, Sciton’s ClearSense Accessory with the JOULE platform and Nd:YAG 1064 nm
laser heats the nail plate resulting in a decrease in nail fungus and subsequent growth of normal nail
proximal to the diseased areas. The treatment involves passing the handpiece across the nail in a
serpentine pattern until the nail plate and proximal and lateral nail folds are heated to a temperature
of 40-42 °C or to patient tolerance. The nail feels warm during the treatment, but there is minimal
discomfort and no downtime. Immediately following treatment, no visual change in the nail is
detectable, as it takes time for the normal nail to grow out. Most infections improve after two 15-20
minute treatments.
Preliminary studies of additional patients show that treatment with the ClearSense Nd:YAG laser is
rapid and comfortable for patients. Adverse events have not been observed and patient satisfaction is
high.
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G.Todd Bessinger, MD, PhD
CONCLUSION
The ineffective treatment of onychomycosis with home remedies, topical antifungals and oral
antifungals means many practitioners and patients desire a safe therapy that can increase the aesthetic
appearance of the nail safely and clear the fungus predictably. Sciton’s ClearSense Accessory with
the JOULE platform and Nd:YAG 1064 nm laser is a safe, effective, and user-friendly modality for
the treatment of onychomycosis. The temperature monitoring capability provides real-time feedback
alerting the practitioner that the optimal treatment temperature has been reached. With this extra
level of treatment monitoring, the patient will enjoy the benefits of a successful treatment without
any adverse side effects. The encouraging results of these patients justify additional studies with more
patients and longer follow-up times (up to 1 year).
REFERENCES
1. Harris DM, McDowell BA, Strisower J. Laser Treatment of Toenail Fungus. In: Kollias N; Choi B; Zeng M; Malek RS; Wong BJ; Ilgner JFR; Gregory KW.; Tearney GJ.; Marcu L; Hirschberg H; Madsen SJ, eds. Proc SPIE, Volume 7161. pp. 71610M-71610M-7 (2009).
2. Ratz J. Onychomycosis. www.emedicinehealth.com/onychomycosis/page 7_em.htm. Accessed December 20, 2011.
3. Package insert, Sporanox, Centocor Ortho Biotech Products, L.P., Raritan, NJ.
4. Sigurgeirsson B, Olafsson JH, Steinsson JB, Paul C, Billstein S, Evans EG. Long-term effectiveness of treatment with terbinafine vs itraconazole in onychomycosis: a 5-year blinded prospective follow-up study. Arch Dermatol. 2002 Mar;138(3):353-7.
5. Hall M, Monka C, Krupp P, O’Sullivan D. Safety of oral terbinafine: results of a postmarketing surveillance study in 25,884 patients. Arch Dermatol. 1997 Oct;133(10):1213-9.
6. Sanmano B, Hiruma M, Mizoguchi M, Ogawa H. Combination therapy consisting of weak pulses of oral terbinafine
plus topical application of terbinafine cream in the treatment of onychomycosis. J Dermatolog Treat. 2004 Jul;15(4):245-51.
7. Nakano N, Hiruma M, Shiraki Y, Chen X, Porgpermdee S, Ikeda S. Combination of pulse therapy with terbinafine tablets and topical terbinafine cream for the treatment of dermatophyte onychomycosis: a pilot study. J Dermatol. 2006 Nov;33(11):753-8.
8. Baran R. Topical amorolfine for 15 months combined with 12 weeks of oral terbinafine, a cost-effective treatment for onychomycosis. Br J Dermatol. 2001 Oct;145 Suppl 60:15-9.
9. Avner S, Nir N, Henri T. Combination of oral terbinafine and topical ciclopirox compared to oral terbinafine for the treatment of onychomycosis. J Dermatolog Treat. 2005;16(5-6):327-30.
10.Gupta AK; Onychomycosis Combination Therapy Study Group. Ciclopirox topical solution, 8% combined with oral terbinafine to treat onychomycosis: a randomized, evaluator-blinded study. J Drugs Dermatol. 2005 Jul-Aug;4(4):481-5.
11.Gupta AK, Uri M, Cooper EA. Onychomycosis therapy: past, present, future. J Drugs Dermatol. 2010 Sep;9(9):1109-13.
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